Provider Demographics
NPI:1376639252
Name:DAVIS, DARRELL MITCHELL (DC)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:MITCHELL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SOUTH HARPER STREET
Mailing Address - Street 2:P.O. BOX 123
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360
Mailing Address - Country:US
Mailing Address - Phone:864-984-6731
Mailing Address - Fax:864-983-1278
Practice Address - Street 1:501 SOUTH HARPER STREET
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360
Practice Address - Country:US
Practice Address - Phone:864-984-6731
Practice Address - Fax:864-983-1278
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2070111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2070Medicaid
SCU631529133Medicare UPIN
SC9133Medicare PIN
SCCH2070Medicaid